This invention relates generally to methods and devices for performing surgical procedures. More particularly, this invention relates to a device useful for coronary revascularization and laparoscopic surgery. The device comprises a system which uses cooled instruments to grasp tissue.
In coronary artery disease, the build up of artherosclerotic plaque on the inner walls of the coronary arteries causes a narrowing or a complete closure of these arteries, resulting in insufficient blood flow to the heart. This condition has become one of the most common life threatening medical problems facing older men and women.
A number of approaches have been developed for treating coronary artery diseases. In less severe cases, it is often sufficient to treat the symptoms with pharmaceuticals and life style modification to lessen the underlying causes of the disease. In more severe cases, a coronary artery blockage can often be treated using endovascular techniques, such as balloon angioplasty, atherectomy, laser or hot tip ablation, stents, and the like.
It is known that long-term relief from coronary artery disease and improved longevity may be achieved through complete revascularization of a patient who suffers from coronary artery stenosis or infarction of the myocardium. Revascularization by coronary artery bypass grafting (CABG) has long been the gold standard of total revascularization. In particular, a CABG procedure in which the left internal mammary artery (LIMA) is anastomosed to the left anterior descending artery (LAD) is well accepted as providing a superior survival rate. However, conventional CABG procedures have significant complication risks which limit their ultimate efficacy. Conventional CABG procedures require the patient to be placed on cardiopulmonary bypass (CPB) support, which requires systemic heparinization and cardiopulmonary arrest.
It is well known that use of CPB produces an exaggerated inflammatory response which may contribute to postoperative end-organ dysfunction. Furthermore, use of CPB has been associated with an increased risk of intraoperative stroke and other embolic complications. CPB also requires systemic heparinization (blood thinning) which contributes to excessive intraoperative and postoperative bleeding. In addition, methods which stop the heart for surgical grafting may contribute to decreased postoperative cardiac function and increase the likelihood of cardiac arrhythmias.
For these reasons, less invasive means of revascularizing the heart have been developed and employed. Consequently, advanced catheter-based therapies, and percutaneous transluminal coronary angioplasty (PTCA) in particular, have risen in popularity to provide less invasive means for treating coronary artery stenosis. These methods have the advantage of being less traumatic and require a shorter recovery time. However, they are not without their own limitations. It is known that PTCA carries significantly higher restenosis and reintervention rates than a CABG procedure for the LAD. The LAD provides the majority of blood flow to the left ventricle, which is responsible for cardiac output to the vital organs. About 80-90% of patients suffering from symptomatic artherosclerosis require revascularization of the LAD, but multi-vessel disease is often present. Accordingly, the use of catheter-based therapies alone to provide complete revascularization is limited in many cases.
New techniques have been developed which allow surgical revascularization without the need for cardiac arrest or CPB. Approximately 20% of coronary revascularization surgery is currently performed without the use of extracorporeal circulation. Such surgeries, referred to as xe2x80x9cbeating heartxe2x80x9d or xe2x80x9coff pumpxe2x80x9d operations, also known as xe2x80x9cOPCABxe2x80x9d, require various means of cardiac stabilization to allow precise vascular anastomoses. Often pharmacological manipulation is combined with external compression stabilizers to further stabilize the operative field. However, this can result in hemodynamic fluctuations which prevent successful completion of these procedures. Furthermore, anastomoses without cardioplegic arrest can lead to regional ischemia as blood flow to functioning myocardium is temporarily occluded.
Topical hypothermia has been employed as an adjunct to ischemic arrest to enhance myocardial protection. However, this has largely been abandoned as extreme hypothermia provides little advantage when used in addition to cardioplegic arrest. In contrast, regional hypothermia may have a significant benefit when applied to non-arrested, functional myocardium.
Certain stabilizers are known to be useful in the OPCAB procedures described above. However, there is a need to have a more effective stabilizer, especially one useful in beating heart surgery.
It is an object of this invention to provide a device useful for surgical procedures, particularly surgery on a beating heart.
It is also an object of this invention to provide a device that increases the efficacy of cardiac or laparoscopic surgical procedures.
It is a further object of this invention to provide a device that is readily available, efficient, and inexpensive.
It is a yet further aspect of the invention to provide a apparatus for surgical applications comprising a longitudinal member capable of cooling tissue.
These and other objects of the invention will become more apparent from the discussion below.
This invention relates to a stabilizer device especially useful in surgical procedures, especially the revascularization of coronary arteries. The stabilizer device comprises a longitudinal member having a cooling member at its distal end, which cooling member is intended to be placed in a position to surround a surgical site. The cooling member and optionally the longitudinal member comprise tubing or one or more lumens through which coolant flows. The temperature of the coolant is sufficiently low that the outer surface of the cooling member and the area adjacent to and within the surgical site is effectively cooled, preferably to a temperature approaching 0xc2x0 C., for example, to a temperature where the cooling member outer surface will grasp tissue due to contact between the outer surface and the tissue. The cooling temperature needed to achieve this xe2x80x9ctarget sitexe2x80x9d temperature may vary from patient to patient. Consequently, this device will have the capacity to cool to temperatures below 0xc2x0 C.
It is anticipated that there may be a slight difference, such as from about 1xc2x0 to 3xc2x0 C., between the coolant temperature and temperature of the cooling member outer surface. The coolant temperature will likely be low enough that the tissue adjacent to or within the surgical site will be at or slightly below freezing, for example, as low as from about 10xc2x0 to about 10xc2x0 C. or from about xe2x88x9210xc2x0 C. to about 5xc2x0 C., preferably from about xe2x88x925xc2x0 C. to about 5xc2x0 C., and more preferably from about xe2x88x922xc2x0 C. to about 4xc2x0 C.
The circulation of coolant in the cooling member is important in cardiac surgery for at least four reasons: First, the circulated coolant provides hypothermic protection to target a site where the myocardium is at the maximal ischemic risk when coronary blood flow is interrupted. Second, the temperature reduction results in myocardial hypocontraction and therefore decreased motion at the target site. This increases target site quiescence. Third, the cooled stabilizer cooling member bonds to the epicardial fat to provide enhanced traction with a minimal compressive requirement. Such bonding provides superior traction and allows for compression or retraction stabilization, as well as minimal epicardial trauma. And fourth, regional cooling induces vasospasm, which limits blood flow to the surgical site and improves visualization.
The present invention involves accessing a patient""s coronary arterial system for the purpose of coronary revascularization, in which heart contractions are not artificially halted. Consistent with conventional open-chest methods, a large opening is typically provided in the patient""s chest by a median sternotomy. This opening enables the surgeon to see the coronary and mammary arteries directly and to position his or her hands within the chest cavity in close proximity to these arteries for manipulation of surgical instruments. During the procedure a retractor remains in place to keep the sternum open.
According to the invention the stabilizer described above is secured in a holder attached to the sternal (or other) retractor. Preferably the holder is adjustable so that the position of the stabilizer can be adjusted relative to the retractor. Also, the stabilizer is preferably adjustable within the holder so that the lower portion of the stabilizer can be positioned on the surface of the patient""s heart.
A device according to the invention can also be used for other surgical procedures, especially any surgical procedure where the cooling member is cooled sufficiently to grasp tissue. A thermostat control system will allow for precise temperature control to maximize epicardial traction while preventing freeze injury. Warmer coolant, for example, liquid or gas, can be circulated to raise the temperature in the cooling member, for example, so that grasped tissue will be released. A laparoscopic instrument according to the invention could be designed to rapidly cool and rewarm. Such an instrument would be useful instead of, for example, bowel graspers, the use of which is potentially injurious to the intestines. It is also within the scope of the invention that the device could be used in robotic surgery as well.
The scope of this invention is not limited to current surgical approaches. This device concept is easily adaptable to other surgical approaches including minimally invasive cardiac surgery techniques involving mini-thoracotomy incisions and including robotically assisted approaches.